I hereby affirm under penalty of perjury that I will accurately complete the attached form listing the names and addresses of all subcontractors or specialty contractors performing work or services related to this permit and return the completed form to the Business License section of the City Treasury Division for approval before requesting final approval of the work. I also hereby affirm under penalty of perjury that at the time I make any subcontract (written or oral) for the performance of any work by a subcontractor or specialty contractor, and which work is to be performed within the City, I will verify that such subcontractor or specialty contractor has obtained the required contractor's City license from the City and will not permit any such contractor to perform any of the work contemplated in any such subcontract (written or oral) unless and until such required contractor's license has been first obtained.

NOTICE: FINAL APPROVAL FOR THIS PERMIT SHALL NOT BE GIVEN UNTIL ALL SUBCONTRACTORS OR SPECIALTY CONTRACTORS HAVE OBTAINED ALL NECESSARY CITY LICENSES AS VERIFED BY THE CITY TREASURY DIVISION

I hereby affirm under penalty of perjury one of the following declarations:

Tenants in dwelling units or mobile homes will not occupy the portion of the property where the construction work will be performed and I have provided any required relocation assistance in full compliance with the provisions of Chapter 4.36 of the Santa Monica Municipal Code.Tenants in dwelling units or mobile homes will occupy the portion of the building where the construction work will be performed but the work will not affect habitability as defined in S.M.M.C. 8.100.010 for more than one workday.I have obtained approval of a satisfactory means and methods plan for tenant protection during construction and will comply with all of its conditions.Tenant protection is not required because the property where the construction work will be performed does not contain one or more dwelling units or a mobile home park.

I hereby affirm under penalty of perjury one of the following declarations:

I declare that I sent the written asbestos notification to the South Coast Air Quality Management District (AQMD) in compliance with AQMD Rule 1403.I declare that written notification of asbestos removal is not required because the alteration includes less than 100 square feet of surface area of asbestos containing materials.I declare that written notification of asbestos removal is not required because I am the owner-occupant of the residential single-unit dwelling and I will conduct the renovation activity.

I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code (and this license is in full force and effect) as follows:

I hereby affirm under penalty of perjury one of the following declarations:

I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Insurance information required below.

Workers' Compensation Insurance Information

Insurance Carrier

Policy Number

WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.

I hereby affirm under penalty of perjury one of the following declarations:

There is no known construction lending agency for the performance of the work for which this permit is issued.The name, branch, designation (if any), and address of the construction lender for the performance of the work are:

I hereby affirm under penalty of perjury one of the following declarations:

The work will be installed on a single family dwelling and/or its accessory structures; ORThe work will not be visible from the street or another adjoining property; ORAny proposed exterior work will be limited to replacing in kind materials, finishes and colors that match the surrounding materials.

I hereby affirm under penalty of perjury that I have read the information shown above on this permit including the declarations and that the above and any attached information that I have submitted in order to obtain this permit are true and correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of the City of Santa Monica to enter upon the above-mentioned property for inspection purposes.